In order for healthcare organizations to receive remuneration from payment organizations (such as insurers or the government) for services provided to a patient, payment requests need be submitted to the payment organizations. These payment requests describe services provided to the patient via a set of standardized codes. The payment organization reviews the codes and then makes a payment.
To represent the healthcare organization's services via codes, a medical coder reviews documents generated in association with the healthcare organization's encounter with the patient. Often these documents are generated by doctors or other healthcare professionals that interact with and provide services to the patient. Examples of such documents include a discharge summary or an operative report. Complex patient encounters (such as a difficult surgery) might yield dozens of documents, each of which will be reviewed by the medical coder. Many of these documents do not adhere to particular formatting. Some of the documents are hand written, or scanned.
Medical coders review these documents and identify billable aspects of the patient encounter, and then associate these billable aspects with codes. This review process, which includes reading, navigating, and assessing documentation, is cumbersome, sometimes requiring up to 70% of a medical coder's time.